Boundaries Patient Registration Form

Fields marked "REQUIRED" are compulsory.. You should only send this form if you are sure that you are eligible to join this practice. Sending this form will NOT automatically register you with the surgery. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

Last Updated: 08/07/2021

Patients Details
















Please help us trace your previous medical records by providing the following










Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK.

If you are from abroad




NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS

If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC)/S1, you may be billed for the cost of any treatment received outside the GP practice, including at hospital).














How will your EHIC/PRC/S1 data be used?

By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process. Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

If you are returning from the armed forces




Communication Needs






Carer Details







Medical History





NHS Organ Donor Registration

Organ donation in England has changed to an opt out system. for further information please go to https://www.organdonation.nhs.uk/.

NHS Blood Donor Registration

For more information, please ask for the leaflet on joining the NHS Blood Donor Register



Family History

Please record any significant family history of close relatives with medical problems and confirm which relative, e.g. mother, father, brother, sister, grandparent.



Allergies


Medication


Your Lifestyle - Alcohol

The score for each response if given in brackets. If you score 5 or more in total for the these questions please complete the Alcohol Audit Questions. One unit of alcohol = small glass of wine, half a pint of beer/cider/lager, single measure of spirits, small glass of sherry, single measure of aperitif. Note 330ml bottle or can = 1.5 units.



Alcohol Audit Questions

Please complete these question if you have scored 5 or more in total from the above section







Your lifestyle - Smoking





About you




Women Only




Students Only



Electronic Prescribing


Patient Participation Group

Would you like to be involved in our Patient Participation Group - we are committed to improving the servcies we provide. The Patient Participation Group is a mechanism for us to gain valuable feedback from our patients about their experiences, views and ideas for improving our services.

Sharing Your Health Record

A Summary Care record is used by staff caring for someone about their medicines and allergies. This means they can look after the person if they are not at their usual doctor’s surgery.



Online Access to your Health Record

For further guidance please see our information sheet - Access to GP Online Services.


Complete Registration